Less invasive care more appropriate for 53% of patients in single-center study

Action Points

Note that this observational study suggested that nearly 50% of ICU care in one medical center was devoted to patients too well, or too sick, to appropriately benefit from that level of intervention.

Be aware that appropriateness of care can be subjective, but re-review of a subset of medical records found relatively high concordance between physicians.

An analysis of intensive care unit (ICU) admissions at a single, large academic center found that more than 50% of admitted patients may have been either too well or too sick to benefit from ICU care.

When investigators examined the medical records of all patients admitted to the intensive care unit of the Harbor-UCLA Medical Center in Los Angeles from mid-2015 to mid-2016, they concluded that more than half could have received adequate care in non-ICU settings, based on ICU priority ranking guidelines by the Society of Critical Care Medicine (SCCM).

The researchers concluded that greater use of the SCCM guidelines for prioritizing patients to the ICU could improve patient care and efficiency and save healthcare dollars.

Priority 3 - critically ill, but reduced likelihood of recovery because of underlying disease or severity of acute illness;

Priority 4 - not appropriate for ICU with equivalent outcomes achievable with non-ICU care based on low risk of clinical deterioration, presence of irreversible illness, or imminent death.

In the newly reported study, researchers prospectively studied the medical records of all (n=808) patients admitted to the Harbor-UCLA Medical Center between July 1, 2015 and June 15, 2016. Reasons for ICU admission and ongoing ICU treatment were evaluated and assigned priority rankings according to the SCCM guidelines.

Each ICU day was ranked using the four priority categories, with a fifth category added to capture patients awaiting transfer out of the ICU.

"We categorized patients needing close monitoring but otherwise receiving care that could be provided outside of the ICU as priority 2, and patients with limited life expectancy or poor prospects for a meaningful functional recovery as priority 3," the researchers wrote. "When priority ranks were uncertain from medical record review, ICU physicians adjudicated (19.9% of cases)."

A total of 80 medical records were randomly selected and re-reviewed by a co-investigator blinded to the study hypothesis and priority ranks assigned, and this investigator agreed with priority rankings 85% of the time.

The analysis revealed that:

Less than half (46.9%) of the patients admitted to the ICU were categorized as priority 1, while 23.4% were categorized as priority 2, 20.9% as priority 3, and 8.8% as priority 4.

More than 50% had priority rankings suggesting that they were either not sick enough (priority 2) or too sick (priority 3) to benefit from ICU care or that they could have received equivalent care outside the ICU (priority 4).

Nearly 65% of total ICU days were allocated to care that was judged to be discretionary monitoring (priority 2), having a low likelihood of benefit despite critical illness (priority 3), or manageable in non-ICU settings (priority 4 and 5).

The findings suggest that "ICU care is inefficient, devoting substantial resources to patients less likely to benefit," the researchers wrote.

"Determining appropriateness of ICU care is complex; in addition to expected benefit, it must incorporate patient preferences, availability of ICU resources, and levels of medical complexity manageable in non-ICU settings. As such, our study cannot fully differentiate between appropriate and inappropriate care," they added.

Chang and colleagues noted that appropriateness of ICU care for critically ill patients with acute illness is often different from those of patients with progressive, irreversible medical comorbidities.

Roughly one in four (26%) priority 3 patients in the study had advanced malignant neoplasms and 27.2% had advanced dementia, "suggesting that many patients in this priority group were at risk for receiving inappropriate ICU care," the researchers wrote.

The single-center nature of the investigation was cited by the researchers as a study limitation.

"While this is a study of just one hospital and results may differ at other medical centers, we suspect that these characteristics of ICU utilization are commonplace and prevalent in many institutions," Chang noted in a press release.

He added that the suggestion that substantial resources in ICU care are being devoted to patients who will not benefit "are a concern for patients, providers and the healthcare system because ICU care is frequently invasive and comes at substantial cost."

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